Future Medical Care in a QME Report: Cure or Relieve, Scope, and Duration

Short answer: the future medical care section of a California medical-legal report answers a benefits question, not a treatment question. Labor Code 4600 requires the employer to provide treatment "reasonably required to cure or relieve the injured worker from the effects of the worker's injury," and the evaluator's job is to say what treatment the industrial injury is reasonably going to require, of what kind, how often, and for how long. That opinion becomes the scope of a future medical award, the number in a settlement that buys the award out, and the basis of a Medicare set-aside where one is needed. Apportionment does not apply to it. A section that says "the applicant may require future medical care" has answered none of those questions.

Session 6 of Perry J. Carpenter, DC, QME's report writing course covers future medical care alongside causation, apportionment, and work restrictions, and the point he makes is the one above: future care is a benefits determination, so the report has to state whether care is needed to cure or relieve the effects of the industrial injury and describe its scope and duration. Session 10 (video) works through treatment and future care reasoning in body-part examples. This piece sets out the framework and a structure for the section.

What cure or relieve means

Labor Code 4600(a) is the source. The employer must provide "medical, surgical, chiropractic, acupuncture, licensed clinical social worker, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury."

Cure and relieve are different things. Cure is treatment aimed at resolving the condition. Relieve is treatment aimed at reducing its effects when it will not resolve. A worker who is permanent and stationary is, by definition, not going to be cured, so most future medical care in a P&S report falls under relieve: medication to control symptoms, periodic therapy to maintain function, injections for flare-ups, replacement of a brace, follow-up visits to monitor a fusion or a joint replacement. Relief is a legitimate and compensable purpose. The section should not apologize for recommending palliative care, and it should not pretend that palliative care will cure anything.

"The effects of the worker's injury" is the causal limit. Treatment for a non-industrial condition is not the employer's responsibility, with one exception the courts have recognized for decades: treatment of a non-industrial condition that is necessary in order to treat the industrial injury is compensable. The classic case is Braewood Convalescent Hospital v. WCAB (1983), where a weight-reduction program was awarded because the worker's industrial back injury could not be treated without it. The evaluator should say so when that applies, and should say the opposite when it does not: that the worker's diabetes, for example, requires ongoing care that is unrelated to the industrial injury and is not part of this opinion.

Where the opinion goes

It helps to know what happens to the section after the report is served, because that is what determines how specific it needs to be.

A stipulated award. If the parties settle by stipulation, or the case is tried, the award includes the permanent disability percentage and, typically, an award of further medical treatment for the industrial injury. The award is open-ended in principle, but the scope of what was industrially injured and what care it reasonably requires comes from the medical-legal reports. A report that clearly ties the recommended care to the accepted body parts defines what the claims administrator will later be asked to authorize.

A compromise and release. If the parties settle by compromise and release, the worker gives up the right to future treatment in exchange for a lump sum. The sum is negotiated from an estimate of what the future care would cost. The estimate is built from the future medical section: the type of treatment, the frequency, and the duration, priced out. A section that says "follow-up as needed" produces no number. A section that says two orthopedic visits per year, a 12-visit course of physical therapy every two years for flare-ups, an epidural steroid injection series no more than once a year, and a probable hardware removal within five years produces one.

A Medicare set-aside. Where the worker is a Medicare beneficiary, or is reasonably expected to become one within 30 months, and the settlement closes future medical, Medicare's interests have to be protected, and above the review thresholds the parties submit a set-aside allocation for approval. The allocation is priced directly from the treating and medical-legal reports. Vague recommendations do not get ignored; they get priced conservatively, which inflates the set-aside and can stall the settlement. Specific recommendations, including specific statements that a treatment is not anticipated, are what allow the allocation to be accurate.

Utilization review. One thing the section does not do is authorize treatment. Since 2013, disputes about whether a particular treatment request is medically necessary go through utilization review under Labor Code 4610 and independent medical review under 4610.5, applying the medical treatment utilization schedule. The QME's future medical opinion frames the award; it does not bind the utilization reviewer on a specific request. Knowing that helps the evaluator write the section at the right altitude: the reasonable course of care over time, not a prescription.

The standard the recommendations have to meet

Labor Code 4600(b) defines medically necessary treatment as treatment based on the guidelines adopted under Labor Code 5307.27, which is the medical treatment utilization schedule, and Labor Code 4604.5 makes the schedule presumptively correct on the issue of extent and scope of treatment. A future medical opinion that recommends care the MTUS does not support, for that diagnosis at that stage, will be authorized only if the presumption is rebutted with scientific evidence.

That does not mean the evaluator has to cite guideline sections for every recommendation. It means the recommendations should be the kind of care the guidelines contemplate for the condition, stated in a way that shows the evaluator knows what the condition's expected course is. Recommending lifetime weekly chiropractic for a resolved lumbar strain invites a fight the recommendation will lose. Recommending periodic evaluation and a limited course of therapy for flare-ups of a fused lumbar spine does not.

The other standard is the one that applies to every opinion in the report. The future medical opinion has to be stated in terms of reasonable medical probability, and it has to set out the reasoning. "The applicant will require future medical care" is a conclusion. "The applicant underwent a two-level lumbar fusion in March 2024; the records document persistent axial pain at every visit since; adjacent segment disease develops in a meaningful fraction of fusion patients within ten years; it is therefore reasonably medically probable that the applicant will require periodic orthopedic follow-up, imaging when symptoms change, and provision for further surgical evaluation" is an opinion the substantial evidence standard recognizes.

Apportionment does not apply

Evaluators sometimes get this wrong in the direction that hurts the worker. Labor Code 4663 and 4664 apportion permanent disability. They say nothing about medical treatment, and the case law is consistent that treatment is not apportioned. An industrial injury that permanently aggravated a pre-existing degenerative spine, and that is apportioned 50% to the degeneration for permanent disability purposes, still carries 100% of the future medical care reasonably required to cure or relieve its effects.

So the future medical section should not say that half the care is industrial. It should identify the care the industrial injury requires, in full, and separately identify care that is required by conditions the industrial injury did not cause or aggravate. The line is causation, not percentage. Apportionment is dealt with in its own section of the report and stays there.

What the section should contain

For each industrial condition, in order:

Current treatment. What the worker is receiving now, from whom, and whether it is working. This anchors the forward-looking opinion in the records.
Anticipated treatment, by type. Physician follow-up, medication by class, therapy modalities, injections, durable medical equipment, diagnostic imaging, surgery. Name the type. "Conservative care" is not a type.
Frequency and duration for each. Visits per year. Courses of therapy and how many visits in a course. Whether the need is indefinite or for a stated period. Whether it is continuous or for flare-ups.
Surgery, stated with probability. If a procedure is reasonably probable, say which one and roughly when. If it is possible but not probable, say that, and say what would change the assessment. Hardware removal, revision, contralateral procedures, and joint replacement after an arthroscopy are the usual candidates.
The causal statement. That the care described is reasonably required to cure or relieve the effects of the industrial injury to the named body parts.
Non-industrial care, separately. What the worker needs for conditions the industrial injury did not cause, stated so the parties can see it was considered and excluded.
The reasoning. The findings, the records, and the clinical course that support each element above.

The section also has to be consistent with the rest of the report. If the permanent and stationary section says the condition is stable, the future medical section should describe maintenance care rather than an active treatment program. If the work restrictions section keeps the worker off ladders because of a knee, the future medical section should address the knee. Dr. Carpenter's broader point about the report as a whole applies here: the sections have to reconcile, because the parties will read them against each other.

Two ways to get it wrong

Boilerplate. The sentence "the applicant should have access to future medical care as needed" appears in a great many reports. It satisfies nothing. It cannot be awarded with any definition, priced for a settlement, or allocated for a set-aside. It also signals to the reader that the evaluator did not think about the question, which colors how the rest of the report is received.

Overstatement. The opposite failure is a section that lists every treatment the condition could ever require, at maximum frequency, for life. Defense counsel will point out that the MTUS does not support it, the utilization reviewer will not authorize it, and a set-aside priced from it will be so large that the case cannot settle, which leaves the worker with an open award and no lump sum. The recommendation that helps the worker is the accurate one.

The middle path is the one the statute describes: reasonably required, to cure or relieve, the effects of this injury.

Where the evidence comes from

The clinical course is the foundation of the future medical opinion, and the clinical course is in the records. How many therapy courses the worker has had and whether each one helped. What the injections did and how long the relief lasted. What the surgeon said at the last visit about further surgery. Which medications have been tried, which were stopped, and why. A future medical section written from a thin summary cannot state that the worker has had three epidural injections with diminishing benefit, because the summary said "injections." The opinion then defaults to boilerplate, not from laziness but from lack of material.

Lexamed builds the treatment history out of the full production as a dated, page-cited chronology, with each course of care, its provider, and its documented result in sequence. The evaluator reads the course of treatment as it actually happened and writes the forward-looking opinion from it. That leaves the physician with the forward-looking judgment and none of the reconstruction.

Frequently asked questions

What is future medical care in workers' compensation? Treatment the injured worker is reasonably expected to need after the condition becomes permanent and stationary, for the effects of the industrial injury. Under Labor Code 4600, the employer must provide treatment reasonably required to cure or relieve the worker from the effects of the injury, and the medical-legal report defines what that treatment is likely to be.

What does cure or relieve mean? Cure refers to treatment intended to resolve the condition. Relieve refers to treatment intended to reduce its effects when it will not resolve. Both are compensable under Labor Code 4600. Most future medical care in a permanent and stationary report is relief: medication, periodic therapy, injections for flare-ups, equipment, and follow-up visits.

Is future medical care apportioned in California? No. Labor Code 4663 and 4664 apportion permanent disability only. Treatment reasonably required for the industrial injury is the employer's responsibility in full, even where the permanent disability is apportioned in part to non-industrial causes.

Does the QME's future medical opinion authorize treatment? No. Specific treatment requests are decided through utilization review under Labor Code 4610 and independent medical review under 4610.5, applying the medical treatment utilization schedule. The QME's opinion defines the scope of the future medical award and informs settlement value.

What is a future medical settlement or buyout? A compromise and release, in which the worker gives up the right to future treatment for the industrial injury in exchange for a lump sum. The sum is negotiated from an estimate of the cost of the future care described in the medical reports, which is why the specificity of the QME's future medical section matters.

What is a Medicare set-aside in workers' comp? An allocation of settlement funds reserved to pay for future injury-related treatment that Medicare would otherwise cover, required where a settlement closes future medical and the worker is a Medicare beneficiary or reasonably expected to become one within 30 months. The allocation is priced from the treating and medical-legal reports.

What should the future medical care section of a QME report include? For each industrial condition: the current treatment, the anticipated treatment by type, the frequency and duration of each, any probable surgery with timing, a statement that the care is reasonably required to cure or relieve the effects of the industrial injury, separate identification of non-industrial care, and the reasoning that supports each element.